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Building Capacity for Clinical Supervision in the Medical Workforce 2017

19 Sep 2017

1. Preamble

1.1. Educating and training the incoming generation of doctors is a significant challenge for governments, health policymakers and the medical profession. Medical graduate numbers have more than doubled since 2005, and the progress of these graduates to prevocational and vocational training is placing intense pressure on Australia’s medical training system. More clinical supervisors need to be found, supported and properly remunerated for this expanding medical workforce.

1.2. As constraints on health funding continue and new funding models are introduced, it is important that training and supervising new doctors continues to be a core component of our health system; high quality supervision and assessment of trainees must not become a secondary activity to service delivery.

1.3. This position statement draws together the AMA’s policies on building capacity for clinical supervision in the medical workforce as the number of local graduates grows, and can be read in conjunction with the other position statements referenced throughout.

2. Clinical supervision in medical practice

2.1. Clinical supervision is an intrinsic part of medical practice. The availability and extent of clinical supervision can have serious implications for the quality of patient care.

2.2. Clinical supervision includes the provision of guidance and feedback on matters of professional and educational development in the context of the trainee’s experience and providing safe and appropriate patient care.1 The AMA supports this definition because it recognises that teaching, supervision and assessment is undertaken in the context of patient care, and that clinical supervisors also have a broader role in ensuring the well-being of students and trainees.

2.3. Medical training in Australia follows rigorous, independently determined standards that require trainees to work in accredited, supervised training positions to gain the experience they need to practise as safe, competent and independent practitioners. The AMA supports the traditional apprenticeship model of training, which is patient-centred and skills-based. This typically involves supervisors demonstrating appropriate skills, abilities and attitudes in the clinical environment, and enables trainees to be directly involved in patient care.2 Effective supervision helps to develop medical professionalism and contributes to improved patient safety, better health outcomes, and faster acquisition of skills by trainees. The supervision must meet the relevant Australian Medical Council (AMC) standards for accreditation.

Patient safety and quality of care

2.4. Patient care provided during clinical placements must be safe, of a high quality and clinically appropriate. This includes appropriate and transparent supervision processes and consistent standards across a diverse range of settings as the number of doctors needing training increases to ensure that the quality and safety of medical practice in maintained.

3. Investing in supervision capacity

Public sector

3.1 Australia is fortunate that many clinicians choose to work in the public health sector to serve the community and to train the next generation of doctors. Though the numbers of trainees entering the training system are increasing rapidly, the number of supervisors in our public hospitals has remained relatively static. There is an ongoing tension between the demand for service delivery and the need to train and supervise trainees. Feedback from our members indicates that there is also insufficient recognition of, and support for, the teaching and training that doctors provide in public hospitals.

3.2 The AMA believes that increased investment in supervision capacity and supporting infrastructure in public hospitals by health authorities is needed to sustain the medical workforce. The quality of medical training will be eroded if investments in clinical supervision and supporting infrastructure fail to keep pace with the growth in trainee numbers. Health systems must commit to provide the human and financial resources necessary to provide effective supervision to ensure that the quality of medical education and training in Australia remains at a high standard. This includes committing to improved subsidy arrangements to attract more supervisors to medical training.

3.3 The AMA supports a funding model that separates teaching and training and recognises that these activities occur alongside service delivery and enhances patient care. A separate funding stream for teaching and training also contributes to an improved educational culture in institutions.

3.4 The allocation of funding should be made on the basis of explicit and transparent criteria and processes. Performance benchmarks must be developed and agreed upon by all levels of government to measure achievement against teaching and training commitments in health services. Benchmarks should not focus on those teaching and training activities that are more easily isolated and costed (such as lectures) at the expense of activities linked with service delivery such as learning by exposure to clinical practice.

Expanded settings

3.5 Medical training in expanded settings is now an important adjunct to the public teaching hospital model that has served Australia well over many years. The AMA believes that greater support is needed for medical training in private hospitals and community settings to meet increased training demands brought about by higher numbers of trainees and changes to how services are delivered. This includes resources in expanded settings for professional support and access to educational resources for supervisors. It is important that training posts involve appropriate service provision and trainees, where possible, have the same opportunities to participate in procedural work as their colleagues in the public system.

General practice

3.6 General practice is the cornerstone of successful primary health care. Funding arrangements must be designed to ensure that general practitioners and other medical practitioners who are involved in the teaching of medical students and doctors in general practice are properly supported to undertake this role. This equally applies to doctors who are supervising general practice trainees in other speciality settings.

Regional and rural settings

3.7 Despite investments by governments to encourage more locally trained, attracting and retaining an adequate health workforce remains a challenge for regional and rural Australia.

3.8 Rural general practices require assistance to improve their available infrastructure to enable them to expand the services they provide to patients, and enhance their capacity to train and supervise medical students and trainees. The AMA believes the Commonwealth Government must provide practice measures, including well-designed infrastructure grants to help rural general practitioners to provide additional consultation rooms, and space for teaching medical students and supervising trainees. Similarly, rural hospitals must be funded by state governments to develop modern facilities to provide an environment that is conducive to delivering a strong and relevant training experience for medical students and trainees with the appropriate level of supervision.

4. Supporting doctors who supervise

4.1 To give clinical supervisors the time they need to train the next generation of doctors, they need improved access to protected time for teaching and training. The AMA has a benchmark for clinical support time, which includes activities associated with high-quality teaching and training. This benchmark specifies that at least 30% of a public hospital senior clinician’s time should be set aside for clinical support work. This figure was arrived at after consultation with the medical colleges in 2008.

4.2 Clinicians with formal management responsibilities as head of department or in other senior roles, and those who are supervisors of training, should have an additional allocation of time for these responsibilities. Specific funding must be made available to support the provision of protected training time in the public hospital system.

4.3 Doctors in training also teach medical students and other doctors in training. Interns, residents and registrars need to be supported in their roles as mentors, teachers and facilitators in formal and informal training environments.

4.4 Appropriate administrative and remuneration will be needed for the specialists who are providing clinical supervision in private and community settings to encourage training in these settings and increase overall supervisory capacity.

4.5 Despite these clear-cut requirements for doctors who supervise, feedback from supervisors and trainees shows that clinical support time in the public hospital system is not being adequately recognised or supported. This includes doctors being actively discouraged from quarantining time for teaching and training activities. Inadequate clinical support time arrangements is also increasing the risk of burn-out among the supervisors who are endeavouring to cope with the time pressures of supervision and medical practice.

4.6 Though AMC accreditation standards for specialist education programs and workplace-based assessment for providers acknowledge the importance of adequate resourcing and support for medical training and education, the AMA believes these standards should be strengthened to ensure that public and private health care institutions and services provide the resources to enable sufficient time for teaching and supervision.

4.7 In 2011, the Commonwealth amended the health insurance regulations to allow supervisors to bill Medicare for procedural services undertaken by a specialist trainee under their direct supervision. Given that exposure to private practice and private hospitals is a now an important component of vocational training, and will take on increasing importance in the years to come, the AMA believes the Commonwealth should amend the Health Insurance regulations to enable supervising specialists to bill Medicare for supervising a specialist trainee during inpatient and outpatient consultations. This measure would boost supervisor capacity by making training in the private sector more widely available for trainees and encouraging greater uptake by private sector health services.

4.8 Supervision is a skill that requires training and development. The AMA supports developing professional standards and competencies for clinical supervision to the extent that they teach broad educational principles and the skills to apply these into the workplace. They should include skills in broader responsibilities for supervisors such as mentoring and personal development. Standards and competencies should not be overly prescriptive. The AMA also supports funding for professional development to develop the supervisory skills of senior clinicians and doctors in training.

5. Fostering a culture within medicine that encourages teaching and training

5.1 The AMA encourages medical practitioners to display a professional commitment and engage in teaching and training of others and supervising the work of less-experienced colleagues. This is an important part of sustaining the profession and delivering high-quality patient care. Teaching and training promotes the sharing of ideas and knowledge and can benefit the recipient and teacher alike.

5.2 The AMA supports formal recognition of supervisors by the medical colleges and health systems. This could be achieved by recognising supervision as part of continuing professional development and awarding doctors who have made significant contributions to clinical supervision and training, and who have provided high-quality service to students and trainees.